‘Give HIV meds to healthy gay men’ was the title of a BBC article on Tuesday this week. The reason for the attention grabbing title was the publication of results from the groundbreaking UK study into PrEP were released on Tuesday at the Conference on Retroviruses and Opportunistic Infections in Seattle. The so-called PROUD study, based on data from 545 participants, showed that PrEP is highly effective at reducing HIV transmission. In the study truvada (an antiretroviral drug) was given to MSM who have had unprotected sex in the three months before enrolling and who were likely to do so again and after 12 months the results were compared for those who were on PrEP and those that weren’t. The group given the drug showed a reduced risk of HIV transmission of 86%. This meant that there were 1.3 new infections per 100 person-years in the group given PrEP immediately, and 8.9 per 100 person-years in the group who were not taking on PrEP. Those who were recruited had an average of 10 partners in the last 90 days .Perhaps the most notable thing about the study results is that they represent the highest efficacy rate of any large scale trial to date, bringing hope that the drug may be approved for use in the UK soon. Sheena McCormack, Professor of Clinical Epidemiology at the MRC Clinical Trials Unit at UCL, and Chief Investigator of the PROUD study, commented:

“These results are extremely exciting and show PrEP is highly effective at preventing HIV infection in the real world. Concerns that PrEP would not work so well in the real world were unfounded. These results show there is a need for PrEP, and offer hope of reversing the epidemic among men who have sex with men in this country. The findings we’ve presented today are going to be invaluable in informing discussions about making PrEP available through the NHS.”

Based on the results of the potentially game-changing study PrEP is shown to be an important option for high risk men who are unable to consistently practice safer sex. Obviously there are questions of cost-effectiveness which will have to be answered before PrEP becomes available on the NHS, but it is likely that soon the UK will follow the US and make PrEP available as one tool to prevent new HIV infections. What do you think about using PrEP to prevent HIV transmission? Do you think this is the right approach to reducing HIV infections in the UK?

This evening, for one night only, we are starting the weekend with a special outreach session at The Place. We are there in partnership with the 201 Dance Company who are presenting their latest production ‘If you leave’. It is a beautiful story of a same-sex relationship and will be part of the Resolution 2015 festival. It is raw, cutting-edge hip-hop with a homosexual twist. We will be there with a supply of sexual health leaflets and other goodies, ready to talk about any of the issues raised in the piece and to make referrals to relevant sexual health and wellbeing services. So, what are you waiting for? If you’re in London tonight why not come down, have a chat with GMI’s very own Rob and Tony, and enjoy the show! We’re there from 7-10pm, and full details of the event can be found here.

When you ask people what sort of HIV prevention campaign is effective, by getting people to test and reducing risk taking behaviours, most people say something shocking is needed – like the falling tombstone used in the UK adverts of the 80s below. But, it this really the best approach, and what are the arguments for and against trying to scare people into having safe sex?

The very fact that most of you reading the blog can recall the tombstone advert seems to demonstrate one advantage of such an approach – done properly it can be extremely memorable, and can attract lots of attention, and really get people talking about HIV. In addition, there is evidence that if someone feels they are equipped to make behavioural changes necessary (whether physically or psychologically) then there is some evidence that this type of approach might have a successful impact. However, the flip side is that such individuals are more likely to already be engaging in safer sex and test frequently anyway, and are (in many ways) not the most useful group to target with HIV prevention messages. In addition, crucially, those that are ‘less well-resourced’ to negotiate safer sex may actually ‘feel even worse when confronted with fear-arousing messaging’ and they might result in feelings of anger or defensiveness which can actually result in unsafe sexual behaviour (see a Sigma report on fear and HIV prevention here for more info).

Other potentially serious consequences of fear based approaches is that they can result in othering of people with HIV and actually increase discrimination as the fear of the virus is transferred to those that have HIV. It can also increase anxiety about HIV which research shows is one of the main barriers preventing people from testing. In addition, there is evidence which shows that fear only translates into behavioural change when people are not fearful, and data from the Gay Men’s Sex Survey shows that most gay men are still HIV and view it as a serious illness. In conclusion, while inducing campaigns can make people more scared of HIV there is little evidence that this would encourage people to make behavioural changes necessary to reduce risk, or increase testing, particularly those that might be seen as most at risk groups.

It is likely that for these reasons HIV prevention campaigns have become less shocking in the last couple of decades. The poster above shows a current campaign by HPE in the UK using the tagline ‘It starts with me’ . Similarly, in New York where HIV prevention campaigns have traditionally been fear-arousing (such as the shocking 2011 NYC department of health advert which included a close-up photo of anal cancer, see here), there has been a move away scare based approaches. For example, the latest HIV prevention campaign by the NYC department of health uses the phrase ‘Be HIV sure’. Dr Daskalakis, who is behind the campaign, claims that its aim is to focus more on health and less on disease. This change in city-wide approach is supported by others working in HIV in New York, such as Terri Wilder of ACT-UP . These ‘softer’ approaches seek to increase knowledge and empower people to make informed decisions through positive terminology, rather than scaring people with explicit imagery and negative wording.

What do you think HIV prevention campaigns should look like? Are dramatic images and shocking phrasing effective, or do you think they are counter-productive?

The views in the article are those of the author and do not necessarily represent those of the GMI Partnership. The GMI Partnership provide rapid HIV testing and outreach work across London. For more information please see their website.

Is it just us or has 2014 flown by?! Here at GMI we have been busier than ever over the last year – we are now working in every LGBT venue across London (including bars, clubs, sex venues and special events) and testing in more places than ever before. We would like to take this opportunity to say thank you to all the venues, organisations and service providers that have supported us in our HIV prevention work throughout 2014. In addition, we would like to thank all of our service users who have tested with us, or come to GMI for advice and information.

Our opening hours at each of our partners over the Christmas period are as follows:

What is it?
PrEP, or pre-exposure prophylaxis, is HIV medication that is taken by people at-risk of exposure to HIV. In the US it is already available and is marketed as ’Truvada’ ( emtricitabine and tenofovir disoproxil fumarate).

Is it available in the UK?
In the UK it is not currently available, but this is likely to change in the near future. PrEP is currently being trialled here in the UK under the PROUD study, where it has been shown to be highly effective. There is currently an NHS England process underway to evaluate PrEP, although this is unlikely to be implemented until 2017. Given the effectiveness of PrEP in previous and current studies we would suggest that procedures should be brought into force as soon as possible that would allow those most at risk to start taking PrEP while the evaluation is ongoing.

Does it work?
Overall, studies show that PrEP is effective at reducing HIV transmission. Indeed, the UK PROUD study and European IPERGAY studies were so effective that everyone in these studies has been offered PrEP. It was viewed unethical to give placebo as a comparison because of this. While research generally shows high efficacy, this varies between study. A study published in 2012 (as part of the iPrEx trial) showed efficacy rates of 99% when PrEP was taken daily, although this fell to 76% when taken twice per week. This study is one example which demonstrates the importance of adherence to treatment for PrEP to be effective. Although figures for the PROUD study have not yet been published they are also likely to also show a high level of efficacy

Who would take PrEP?
When PrEP is approved in the UK it will be taken by those who are at high risk of seroconverting (becoming HIV positive). This would include three main groups: 1) serodiscordant couples 2) people who are unable to insist on condom use, and 3) other high risk populations such as injecting drug users.

Do we really need PrEP?
PrEP is a vital addition to the toolbox of HIV prevention strategies. It can allow those unable to consistently engage in protected sex to reduce the risk of HIV transmission. It can also be used when needed to match changing sexual behaviour. However, for PrEP to be effective (and especially to encourage adherence) it must be part of a wider HIV prevention strategy focused on behavioural approaches (e.g. counselling and one-to-one work).

PrEP Statement
In November 2014 a joint statement on PrEP was issued by community organisations working on HIV prevention, including the GMI Partnership organisations (Metro Centre, Positive East and West London Gay Men’s Project). The statement outlines the need for PrEP, gives information on its efficacy and, speaks to commonly highlighted barriers to the introduction of PrEP. Importantly, the statement also demonstrates that there is an emerging consensus amongst sexual health and HIV charities that PrEP is supported across the field. It also represents an attempt to collectively lobby for action, including for the immediate provision of PrEP for most at risk populations.

On April 6th this year self-testing HIV kits were approved in the UK, following a government amendment to the law, and within the next few months it is likely they will be available to buy over-the-counter for the first time. So, what is a self-testing kit?

A self-testing kit is a do-it-yourself test for HIV which uses saliva or a blood sample to provide an instant result. It is different to a home sampling/screening test where the test is done at home and then sent away for laboratory analysis, normally providing a result within 3-5 days.

Currently self-testing kits are not yet on sale in the UK and no companies have applied for a license to sell self-testing kits within the EU, even though they are now legal here. When they are finally on sale they will carry the CE mark to show they can be used safely.

What are the advantages of self-testing for HIV?

Reaction to self-testing kits has been largely positive, as reflected in this comment by a spokesperson for the Royal Pharmaceutical Society, who said “”HIV self-testing kits may help increase diagnosis by providing more choice for people who have been at risk but are reluctant to get a test in person from existing services.”

Convenience: There is no booking appointments, no waiting times and no going to the clinic so self-testing is a convenient way to do an HIV test.

Privacy: Doing the test from your home is private and anonymous and you don’t need to talk to anyone about doing the test, which might be preferable for some people.

For these reasons it is possible that self-testing will increase the likelihood that those who have never tested/test infrequently know their HIV status and, as a consequence their use could result in a drop in undiagnosed HIV cases and late diagnoses.

Are there any disadvantages?

Cost: Self-testing kits need to be bought and aren’t available for free like home sampling/screening tests.

Support: When testing at a clinic or pop-up testing service you speak to a trained advisor who is able to have a pre-test discussion, answer any questions and signpost to appropriate services.

Misdiagnosis: There is some worry that people who don’t understand the test might misinterpret the result, although there were similar concerns about pregnancy testing and this is now commonplace.

Other ways to test:
Self-testing and home sampling are great additions to current testing options, but are not appropriate/preferable for everyone.

NB – If you have had unprotected sex in the last 72 hours (and there is risk of HIV transmission) it is possible to take Post-exposure prophylaxis (PEP) to reduce the chance of transmission. PEP can be obtained from and sexual health clinic or accident and emergency department.